Hobby Lobby and the contraception it opposed

In the recent Hobby Lobby decision addressing the Affordable Care Act's insurance mandate for women's contraception, the U.S. Supreme Court raised several issues about religious freedom and the rights of corporations. What it didn't consider was whether the contraceptive methods objected to by Hobby Lobby — specifically intrauterine devices (IUDs) and emergency birth control — actually are abortifacients as the company suggested. The court ruled that it was enough for the company (owners) to think so.

To find out the mechanisms of these birth control methods, I consulted a couple of experts, both physicians.

Here are the basics. The IUD is a "small T-shaped device" inserted into the uterus. It must be inserted by a qualified health-care provider and has a one-time cost of between $500 and $1,000; it lasts for between three and 12 years depending on the style chosen.

There are two types of IUD, the 12-year copper device, marketed under the name ParaGard; and the shorter-lasting more popular hormonal device that releases a small amount of progestin, sold under the names Mirena and Skyla.

According to the Planned Parenthood website, both styles work by affecting the way sperm move so they are unable to join with an egg. Further, hormonal IUDs may prevent an egg from leaving the ovary. Progestin also works to prevent pregnancy by thickening a woman's cervical mucus which blocks the sperm.

The ParaGard, in addition to its long-time use, can be used as emergency birth control if inserted within five days of unprotected intercourse. "It's a common misconception that fertilization occurs at the moment of passion," said Dr. Wendy Klein, a Richmond-based internist who specializes in women's health. "It can take several days. It's a complicated process."

Klein reduced the action of the IUD to two mechanisms: the prevention of ovulation and the inhibition of fertilization by changing the environment. She added that "the evidence supports the prevention of fertilization, rather than the prevention of implantation of fertilized eggs."

However, there may be a small percentage of ParaGard users in whom the egg is fertilized and prevented from implantation, said Dr. Jeffrey Henke, OB/GYN, of Riverside Womens Healthcare in Newport News. He emphasized that it is not the primary mechanism by which the copper-based IUD works and noted that the Mirena and Skylar are "dramatically different and by far the most popular."

Henke, who is chief of women's health line services for Riverside, acknowledged some "controversy in studies" regarding emergency contraception and pointed out the inherent problems in establishing data due to the difficulty of conducting randomized studies in humans. However, the primary way that Plan B — the most common, progesterone-based emergency contraception — works is by inhibiting ovulation, he said. And, what is undisputed, he added, is that its use is much more effective if taken before ovulation.

"If you take it after ovulation, it may not help at all," he added. Last year the FDA changed the labeling on emergency contraception to indicate that it serves to delay or block ovulation.

What is also known — as accepted by the National Institutes of Health, the U.S. Food and Drug Administration and the American Congress of Obstetricians and Gynecologists, according to Henke — is that emergency contraception does nothing to interrupt an established pregnancy.

Currently, there are two forms of emergency contraceptive pills that are FDA-approved, Klein said. One requires no prescription and is available over the counter, while the newer, "more effective" pills require a prescription.

Henke noted that there is no medical reason for any emergency contraception to require a prescription and called its requirement "value-driven."

Both physicians emphasized the importance of easy access to contraception as essential to women's health.

The ACA mandate

According to the government's website http://www.healthcare.gov, the Affordable Care Act established the following requirements for insurance coverage: "Plans in the Health Insurance Marketplace must cover contraceptive methods and counseling for all women, as prescribed by a health care provider. These plans must cover the services without charging a copayment, coinsurance, or deductible when they are provided by an in-network provider.

Plans aren't required to cover drugs to induce abortions or services related to a man's reproductive capacity, such as vasectomies.

More online

Follow the blog at dailypress.com/healthnotes. Find more health news at dailypress.com/health; on Twitter @dphealthnotes or on Facebook at http://www.facebook.com/dphealth. Sign up for a free weekly health e-letter, The Health Report, at dailypress.com/services/newsletter/register/.